January 26, 2012 Porcupine Northeastern Ontario Mines Safety Groups Mario Vottero KAPUSKASING...

January 26, 2012

Porcupine Northeastern Ontario Mines Safety Groups

Mario Vottero

KAPUSKASING PHOSPHATE OPERATIONS

December 22 2011 Lost Time Injury

PNOMSG, January 26, 2012

KPO Surface Mine Contractor• Flipped 100 Ton 777D • Critically Injured• Multiple fractures to right leg• Fracture to neck• Injuries to hip

MOL is investigating this critical injury

December 22, 2011 7:25 pm

On December 22, 2012, 7:25 pm a Haul Truck Operator was in the process of dumping his first load of waste material in the centre pit dump area. As he backed up to the dump edge he failed to stop before the berm, drove through it backwards, down the embankment (angle of repose approximately 70 degrees, 15 meters high).


Pictures


Injuries


The momentum caused the 100 ton haul truck (777D Caterpillar dump truck) to flip over and land upside down on top of its load. The Emergency Response Team was immediately activated; the injured haul truck operator was lifted onto stretcher and transported by ambulance to the hospital. As a result of the impact forces and not wearing a seat belt the injured worker suffered fractured neck, multiple fractures to his upper right leg, and injuries to the right side of his hip.

Pictures


Causes


• Poor visibility – Night time operation with insufficient illumination of dump area, and due to cold temperature (-27ºC) vehicle exhaust fumes blocking line of sight of intended path of travel.

Causes


• Procedure not followed – The Contractor’s Dumping Procedures were not followed by the dozer operator, haul truck operator and supervisor;

– Haul Truck Operator failed to stop when visibility was impaired.

– Dozer Operator failed to spot haul truck operator.– Supervisor failed to ensure operational readiness and

also allowed dumping operation to continue without proper illumination.

– Seat belt was not worn, which aggravated the injury

Key Recommended Actions


• Contractor Dumping Procedures will be revised to;

–clearly define roles and responsibilities,–Implement a checklist to ensure

requirements are met before dumping,–And communication directives between

the Dozer Operator and Haul Truck Operator.



• Seat belts will include a high visibility shoulder strap. When worn the high visibility strap will enable compliance monitoring.

• Modifying exhaust system on haul trucks to minimize poor visibility during cold conditions outside.

• Implementing procedure outlining responsibilities for light plant set up in dump areas.

• Haul truck involved in the incident will be inspected by the manufacturer for defects that may have caused or contributed to the incident.



• Investigating the use of camera system to mitigate visibility issues.

• Evaluating berm construction standard with respect to mining material available at KPO

• Implement a routine planned inspection process for Contractor’s Supervisor, Management and EHS Personnel to assure compliance.

• Conduct a root cause analysis using cause mapping process to understand why procedures were not followed

Root Cause Analysis


For more information on Root Cause Analysis

ThinkReliabilitywww.thinkreliability.com281-489-2904 office


Questions ?

January 26, 2012 Porcupine Northeastern Ontario Mines Safety Groups Mario Vottero KAPUSKASING...

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